Prudential Mutual Fund Services LLC (PMFS) a Prudential Financial company Instructions Request for IRA Distribution (Spouse and Non-Spouse) For assistance: Clients (800) 225-1852 Pruco representatives (800) 542-7117 Financial professionals (888) 778-5471 Use this form to request a distribution from an Individual Retirement Account (IRA) due to the death of an IRA owner for which you are the surviving spouse or a non-spouse beneficiary. In addition to completing this form, we request a copy of the IRA owner's certified death certificate. In some cases, additional documentation may be required. Note: If the beneficiary is a nonperson or entity, such as the IRA owner s estate or trust or charitable organization, then please use the Request for IRA Distribution (Entity) form (MF1024C). We have presented this information based on our understanding of the applicable tax laws. We suggest that you consult with your tax adviser because neither we, nor our representatives, can provide tax advice. You may consult IRS Publication 590 Individual Retirement Arrangements for additional information by contacting the IRS Forms Distribution Center at (800) 829-3676 (TAX-FORM) or by downloading Publication 590 from www.irs.gov. On these pages, I, my, you, and your refer to the account owner or beneficiary(ies). We, us and our refers to PMFS. Mailing Instructions Standard Prudential Mutual Fund Services LLC mail to: PO Box 9658 Providence, RI 02940 Overnight mail to: Prudential Mutual Fund Services LLC 101 Sabin Street Pawtucket, RI 02860 1 Deceased IRA Owner 2 Current 3 Associated Person Identity Verification Indicate the deceased IRA owner's account number, name, Social Security number, and date of death. Your (spouse/beneficiary) name, Social Security number, date of birth, complete mailing address, and daytime and home telephone numbers. USA Patriot Act requirements To help the government fight the funding of terrorism and money laundering activities, Prudential Financial is required to obtain, verify, and record information on each person who opens an account or beneficiary who inherits an IRA. Important The following information is required for each person associated with the account: Name Residence address Date of birth Taxpayer ID number (SSN or EIN) If this information is not provided, we will be unable to complete your request. If we are unable to verify your identity, Prudential Financial reserves the right to take any step we deem reasonable. Page 1 of 10
4 Spouse Options 5 Non- Spouse Options 6 Your IRA Designation 7 Decedent s Required Minimum Distribution (RMD) 8 New Owner's RMD Option 1: As the surviving spouse and sole beneficiary, you may elect to roll over the decedent's IRA into your own IRA account with PMFS and begin taking required minimum distributions at age 70½. Please indicate your existing IRA account number with PMFS or a new fund/account will be established for you. Note: If an IRA has multiple designated beneficiaries as of September 30 of the year following the IRA owner's death, the beneficiaries must separate the accounts by December 31 of the year following the year of the IRA owner's death in order for the surviving spouse to be eligible to roll over the IRA into his/her own. Otherwise, distributions will be based on the life expectancy of the oldest beneficiary and will begin by December 31 of the year following the year of the IRA owner s death. Option 2: Request a distribution of the account proceeds as a lump sum payment or reinvest the proceeds into a non-ira account. Option 3: Elect to have your shares transferred into a new account for your benefit, and take distributions (based on your life expectancy) by December 31 of the year following the year of the IRA owner's death. You may also designate your own beneficiary(ies) for this account in section 6. If the owner died prior to receiving his/her required minimum distributions for age 70½ and was waiting to take those distributions until April 1 after the year he/she attained age 70½, then the spouse, as the sole beneficiary, may either defer distributions until the IRA owner would have been 70½, or distribute the account by the end of the fifth year following the year of the IRA owner's death. Note: If you choose option 3, you must also complete section 8. Option 4: You may wish to roll over the IRA into your own IRA or another qualified account at another institution. Please provide the name, address, and account number of the financial institution that will receive the proceeds. A letter of acceptance from the accepting custodian should accompany this form. Option 1: Elect to have your shares transferred into a new account for your benefit, and take distributions (based on your life expectancy) by December 31 of the year following the year of the IRA owner's death. You may also designate your own beneficiaries for this account. Note: If an IRA has multiple designated beneficiaries as of September 30 of the year following the IRA owner's death, the beneficiaries must separate the accounts by December 31 of the year following the year of the IRA owner's death in order for the surviving spouse to be eligible to roll over the IRA into his/her own. Otherwise, distributions will be based on the life expectancy of the oldest beneficiary and will begin by December 31 of the year following the year of the IRA owner s death. Option 2: Request a distribution of the account proceeds, either as a lump sum payment, or reinvest the proceeds into a non-ira account. Note: If you choose option 1, you must also complete section 8. Complete this section to indicate your primary and secondary beneficiary(ies). The total percentages for each beneficiary classification must equal 100 percent. Indicate if the IRA owner was age 70½ or older and satisfied his/her required minimum distribution (RMD) in the current year. Complete this section if you selected beneficiary option 3 in section 4 or option 1 in section 5. Note: Distributions are generally required to begin by December 31 following the year of the IRA owner's death. You may also use this section to elect to defer distributions if your spouse died prior to reaching age 70½. Page 2 of 10
9 Special Mailing Instructions for Distributions 10 Bank Account 11 Tax Withholding Election 12 Signature Guarantee Complete this section to request that payments be mailed to an address other than the address provided in section 2. Note: This applies only to beneficiary option 2 in section 4, option 2 in section 5, or section 7. Complete this section to request payments authorized in section 4, 5, or 8 to be wired or electronically sent to your bank account. Note: Amounts under $500 will not be wired and will be sent by check. Indicate what percentage, if any, PMFS should withhold for income taxes. We present this information based on our understanding of tax law. You may wish to consult with a tax or legal adviser because neither we nor our representatives can provide tax or legal advice. Federal and state income tax withholding. Federal and some state tax laws require us to withhold income taxes from certain cash payments unless you elect out of withholding and in certain other circumstances. We are required to withhold federal income taxes and certain state income taxes from the taxable portion of any withdrawal from a nonqualified annuity, an IRA, a Roth IRA, a Section 403(b) tax-deferred annuity, or a Section 401(a) qualified plan. If your withdrawal is from a Section 403(b) tax-deferred annuity or a Section 401(a) qualified plan, and is an eligible rollover distribution, you will not be able to elect out of federal income tax withholding. Federal taxes will be withheld at a 20 percent rate unless you elect to have your eligible rollover distribution directly rolled over to an IRA or to another qualified plan. You will not be able to elect out of withholding if we are notified that your taxpayer identification number (TIN) is incorrect. Estimated tax and possible penalties. If you elect to have no income tax withheld from your withdrawal, or if you do not have enough income tax withheld from your withdrawal, you may be responsible for payment of estimated tax. You may incur penalties if your withholding and estimated tax payments are not sufficient. You may be subject to IRS penalties, including fines and imprisonment, if you fail to provide your correct taxpayer identification number (TIN), fail to report taxable interest or dividends on your tax return, or give false tax information. You may also be subject to a 10 percent federal income tax penalty if you are under the age of 59½ and you are taking a withdrawal. You must have your signature medallion signature guaranteed under certain circumstances. See section 12 of the form. 13 Tax Certification and Signature (Please sign and date where indicated. We cannot process this form without your signature.) Taxpayer identification number and U.S. citizenship. You must include your TIN in section 13. If the account owner is an individual, this is the Social Security number. You must state whether you are or are not a U.S. citizen. If you are not a U.S. person (including resident alien), you must provide the country of which you are a citizen and submit the applicable IRS Form W-8(BEN, ECI, EXP, IMY). In most situations, the IRS Form W-8BEN will be the appropriate IRS Form W-8. Backup withholding. You must tell us if the IRS has notified you that you are subject to backup withholding because you did not report all your taxable interest and dividends on your tax return. You are not subject to backup withholding if you did not receive such a notice from the IRS, or if the IRS recently told you that you are no longer subject to a backup withholding order. If you have been notified that you are subject to backup withholding, please check the appropriate box in section 13. If the account is held by a trustee as agent for an individual or by a grantor trust, the individual for whom the account is held or the grantor must complete a substitute Form W-9 and attach it to this form in order not to be subject to backup withholding. Page 3 of 10
Please print using blue or black ink. 1 Deceased IRA Owner Account number Fund name Name of IRA owner (first, middle initial, last name) IRA Distribution Form (Spouse and Non-Spouse) Social Security number Date of death (mo., day, year) 2 Current Name of beneficiary (first, middle initial, last name) Social Security number Mailing address: Street Apt. Residence or legal address (if different than mailing address above): Street Apt. Daytime telephone number Extension Home telephone number 3 Associated Person Identity Verification (Required for the USA Patriot Act.) All associated persons (current beneficiaries) must complete a separate distribution form with all the information requested. Name of associated person (first, middle initial, last name) Social Security number Account mailing address: Street Apt. Residence/Permanent address (We cannot accept a PO Box.): Street Apt. Daytime telephone number Extension Home telephone number E-mail address (optional) (continued) Page 4 of 10
3 Associated Person Identity Verification (continued) Citizenship U.S. person I am not a U.S. person (including resident alien). I am a citizen of* Resident alien *Nonresident aliens must attach the applicable Internal Revenue Service (IRS) Form W-8(BEN, ECI, EXP, IMY), which can be obtained at www.irs.gov. Non U.S. citizens must provide valid government-issued proof of identity, if you have not provided your tax identification number. Identification (ID) type Passport Number Expiration date Issuing country U.S. Visa Number Expiration date U.S. Alien ID Card Number Expiration date Employment Status Employed Unemployed Retired Prudential employee Occupation Employer 4 Spouse Options (Choose only one of four options.) Marital Status Married Single Widowed Divorced Number of dependents Highest education level achieved Post graduate work College graduate Attended college High school graduate Attended primary/high school Technical or vocational school Associated member of a broker/dealer Yes No This section is for spouse beneficiaries ONLY. Non-spouse beneficiaries should skip to section 5. 1. Roll over to a new or existing IRA at PMFS. Note: The current investment allocation on the decedent's IRA will be carried over to the new IRA for the beneficiary. If existing, please provide account number. 2. Distribute the total amount of my portion in: a lump sum, or to a non-ira account. (Any new fund will require a completed non-ira application. Note: All distributions will be reported as taxable distributions.) If existing, please provide account number. 3. Transfer my portion of the account to a new inherited IRA under my name and Social Security number. Note: The current investment allocation on the decedent's IRA will be carried over to the new inherited IRA for the beneficiary. 4. Distribute to the following institution*: Name of institution Street Account number *Note: It is your responsibility to confirm that the receiving plan accepts these types of distributions. A letter of acceptance from the accepting custodian should accompany this form. Page 5 of 10
5 Non- Spouse Options This section is for non-spouse beneficiaries ONLY. 1. Transfer my portion of the account to a new inherited IRA under my name and Social Security number. Note: The current investment allocation on the decedent's IRA will be carried over to the new inherited IRA for the beneficiary. 2. Distribute the total amount of the portion in: a lump sum, or to a new non-ira account. (Any new fund account will require a completed non-ira application. Note: All distributions will be reported as taxable distributions.) If existing, please provide account number. 6 Your IRA Designation This section must be completed if you selected option 3 in section 4 or option 1 in section 5. Please provide your beneficiary information below. The total percentages for each beneficiary classification must equal 100 percent. Primary beneficiary A. Name (first, middle initial, last name) B. Name (first, middle initial, last name) C. Name (first, middle initial, last name) Total percentage for all primary beneficiaries Secondary/Contingent beneficiary 1 0 0 A. Name (first, middle initial, last name) B. Name (first, middle initial, last name) C. Name (first, middle initial, last name) Total percentage for all secondary beneficiaries 1 0 0 Page 6 of 10
7 Decedent s RMD 8 New Owner s RMD If the IRA owner was 70½ or older, did he/she satisfy his/her required minimum distribution (RMD) requirement in the year of death? Yes No If No or nothing is checked, a check representing the required minimum distribution amount will be sent to you. If there are multiple beneficiaries, the required amount will be divided accordingly. Complete only if either option 3 in section 4 or option 1 in section 5 was chosen. Calculate distribution based on life expectancy. Frequency: Monthly Quarterly Semiannually Annually Date of first distribution month day year 9 Special Mailing Instructions for Distributions 10 Bank Account I elect no payment at this time due to the death of the IRA owner prior to age 70½. I understand that the account must be distributed by December 31 of the fifth year following the owner s death or as the surviving spouse I can defer my payment until the decedent would have been age 70½. Please mail the distribution authorized in section 4, 5, 7, or 8 to the following address. Street If you would like the distribution authorized in section 4, 5, or 8 to be sent electronically to your bank, complete this section and attach a voided check or deposit slip. Note: The name of the beneficiary must appear on the bank account specified. Bank name Apt. Bank account number ABA routing number (To ensure accuracy, verify with your bank.) Name of depositor on bank records (first, middle initial, last name) Type of account Checking Savings Name of joint depositor on bank records (first, middle initial, last name) Attach voided check here. Name on bank account Check no. 1234 Street address City, State ZIP DATE PAY TO THE ORDER OF $ FOR VOID DOLLARS 123456789 ABA number (9 digits) 55555 5 55555 1234 Bank account number Page 7 of 10
11 Tax The taxable portion of the withdrawal that you receive will be subject to federal income tax withholding and Withholding state income tax withholding, where applicable, unless you elect not to have withholding apply. The taxable Election portion of your withdrawal will normally be subject to federal income tax withholding at a rate of 10 percent for non-annuity payments, and is based on withholding tables for annuity payments. Your withdrawal may also be subject to state income tax withholding in certain states. Please note that if you are a U.S. citizen and your address of record is a non-u.s. address, we are required to withhold income tax unless you provide us with a U.S. residential address. If applicable, please include your U.S. residential address with this form. By signing and dating this form and making no entries in this section, you can elect not to have any taxes (federal or state) withheld, but you will still be liable for payment of any taxes due. Please check the appropriate boxes if you want to have federal and/or state income tax withheld. Withhold 10 percent federal income taxes on the taxable portion of my distribution. (If you want to have more than 10 percent withheld, please indicate it in the box below.) Percent (minimum 10 percent) or Dollar amount $,. (Amount cannot be less than 10 percent of distribution.) If you want to have state income taxes withheld from the taxable portion of your withdrawal, please complete the appropriate box(es) below. Please be advised that if your resident state requires mandatory withholding, we will withhold the default amount your state requires if you elect no withholding. Withhold state income taxes on the taxable portion of my withdrawal based on the following criteria: Percent or Specific dollar amount $,. Note: The percent or dollar amount cannot be less than the minimum required by your state of residence. If the amount you selected is less, we will withhold the required amount. 12 Signature Guarantee You must have your signature medallion signature guaranteed under the following circumstances: If the distribution exceeds $10,000 and is payable to a special payee or is mailed to a special address (other than Prudential or the current beneficiary*). If the distribution exceeds $100,000. If the distribution is mailed to a special address that is a P.O. Box, regardless of the dollar amount. If the distribution is made by wire and payable to a special payee (other than Prudential* or the current beneficiary), regardless of the dollar amount. *If the distribution is a Transfer of Assets (Custodian to Custodian), a medallion signature guarantee is not required. The medallion signature guarantee may be obtained from an authorized officer from a bank, broker, dealer, securities exchange or association, clearing agency, savings association, or credit union that is participating in one of the recognized medallion programs (STAMP, SEMP, or NYSE MSP). The medallion signature guarantee must be appropriate for the dollar amount of the transaction. Prudential Mutual Fund Services LLC reserves the right to reject transactions where the value of the transaction exceeds the value of the surety coverage indicated on the medallion imprint. Name of guarantor institution X Signature of authorized officer providing signature guarantee Affix medallion signature guarantee stamp here Page 8 of 10
13 Tax Certification and Signature (We cannot process this form without your signature.) If this section is not completed, we may not be able to honor your election out of withholding. Complete (a) or (b) below: (a) Under penalties of perjury, I certify that my correct taxpayer identification number is: s Social Security number s date of birth month day year Complete the following, if applicable: I am not subject to backup withholding for the reasons stated under backup withholding in the instructions to the tax certification section. (Check the box only if you are subject to backup withholding.) I have been notified by the IRS that I am subject to backup withholding due to underreporting of interest or dividends. (b) I am not a U.S. person (including resident alien). I am a citizen of Attach the applicable IRS Form W-8(BEN, ECI, EXP, IMY). By signing below, I certify and acknowledge that the information provided on this form is correct. The IRS does not require your consent to any provision of this document other than certification required to avoid backup withholding. X s signature month day year Page 9 of 10
14 Financial Professional(s) Identification and Signature(s) (if applicable) Your new IRA or inherited IRA will be automatically set up with the same financial professional as the decedent's existing IRA unless the section below is completed. If you would like to make a change, please have your new financial professional complete the following section. Pruco Securities registered representatives must complete the USA Patriot Act Customer Identity Verification form and submit it with this form. 1. Financial professional (first name, MI, last name) (Please print.) Financial professional s signature X Broker/dealer name (Please print.) Broker/dealer number Financial prof.#/contract # Branch office #/Agency code Percent Office phone number Alternate phone number 2. Financial professional (first name, MI, last name) (Please print.) Financial professional s signature X Broker/dealer name (Please print.) Broker/dealer number Financial prof.#/contract # Branch office #/Agency code Percent Office phone number Alternate phone number Page 10 of 10